Today’s lectures focused on patient evaluation and treatment with surgery and oral appliances.
Dr. Peter Cistulli from the University of Sydney discussed findings from the MASPAP randomized trial conducted in Australia that has recently been accepted for publication in a medical journal. This study compared mandibular advancement splints (also known as oral appliances) against continuous positive airway pressure (CPAP), with every person in the study undergoing 1 month of treatment with each. The study showed that the oral appliance did not lower the apnea-hypopnea index as much as CPAP, but there were similar improvements for both treatments in sleepiness, quality of life, and a number of other measures. There is growing evidence that oral appliances can work well for many patients, and two major questions are who responds best to oral appliances and how much patients wear them over time. As with surgery, many studies have tried to identify patients who respond best. As far as usage, my personal experience (and that in long-term studies examining use) is that some patients do very well, but there can be important dropoffs in the ability to wear these and achieve benefit over time (this can also be true for any treatment, including CPAP and surgery).
Dr. Edward Weaver from the University delivered excellent lectures on the evaluation and treatment of the nose and outcomes for palate surgery. Ed’s ability to provide common-sense, straightforward, informative, humorous, and compelling lectures is remarkable. He described the important benefits, seen in long-term studies, of palate surgery that have been shown for sleepiness, quality of life, cardiovascular disease, and mortality. Most of the evidence is based on uvulopalatopharyngoplasty because it was the first procedure (other than tracheotomy) to be described for sleep apnea, but the expectation is that the current arrays of sleep apnea procedures, including many alternative soft palate procedures and others that are directed at what I call the Tongue Region, may be even better.
Dr. Richard Schwab and I discussed evaluation of snoring and sleep apnea patients, especially their throat (pharynx), with techniques such as drug-induced sleep endoscopy and magnetic resonance imaging. Research in this area has added to our understanding of snoring and obstructive sleep apnea, how various factors such as obesity may play a role in the disorder, and the potential to use these and other techniques to develop targeted, effective treatment plans. We both are conducting ongoing research examining these questions.
Dr. Andrew Goldberg presented snoring treatments, including nonsurgical treatments like snore pillows or snore sprays as well as procedures like the Pillar Procedure, palate radiofrequency, injection snoreplasty, and different techniques of uvulopalatoplasty. There has been extremely limited side-by-side comparison of these techniques and technologies. The available evidence shows that the Pillar Procedure has better long-term outcomes than the alternatives, but it is also clear that not all patients with snoring respond equally or forever. Andy’s presentation, consistent with my practice and experience, emphasizes the importance of patient evaluation to select the best candidates (or the best procedure for each patient). In another lecture, Andy also discussed the medical risks of sleep apnea surgery and optimal management to reduce those risks.
Modern sleep apnea surgery includes a number of soft palate procedures other than uvulopalatopharyngoplasty. Dr. Tucker Woodson from the Medical College of Wisconsin spoke about these procedures, especially expansion sphincter pharyngoplasty and palatal advancement. I had dinner the night before with Tucker and discussed two modifications to the procedure technique introduced by Italian surgeons, and he shared those with the audience.
Dr. Kasey Li discussed tonsillectomy and adenoidectomy for the treatment of sleep apnea in children, highlighting the fact that these achieve marked improvement in most children but a resolution in only 60-70%. Researchers are more closely identifying the children who do not respond as well: obese children, racial and ethnic groups other than Caucasians, and those with worse sleep apnea prior to surgery are less likely to have resolution of their sleep apnea with tonsillectomy and adenoidectomy. In addition, there may be a worsening in children with sleep apnea over time. Kasey sees many referrals of children with craniofacial conditions, and he treats them somewhat more aggressively when necessary. He works closely with orthodontists using interventions such as rapid maxillary expansion that can widen the upper and lower jaws and thereby open space for breathing. Kasey also spoke about maxillomandibular advancement in adults, indicating that 85-90% of patients achieve marked improvement in sleep apnea. He also has identified some of the factors associated with results: degree of advancement of the jaws (at least 8-10 mm) and age (above 60 years of age do poorly). The last point is particularly important, as I see a number of older patients who have been told that they should undergo maxillomandibular advancement, typically by people that have never performed the procedure.
Dr. Erica Thaler from the University of Pennsylvania spoke about her experience with robot-assisted tongue surgery (basically, an extended lingual tonsillectomy). Robotic surgery has received tremendous attention over the past couple of years, not just for sleep apnea but for surgery of the prostate, gastrointestinal tract, gynecological tract, and head and neck. An article in the Journal of the American Medical Association indicated that most hospitals in the United States advertise their ability to perform robot-assisted surgery on the front page of their website without any discussion of potential risks or the limited experience with this technology for various uses. I credit Erica and others like Claudio Vicini in Italy for their research leading the way in learning how necessary technology like the robot is for sleep apnea. The da Vinci robot manufactured by Intuitive Surgical can improve the surgeon’s ability to see, but I perform this procedure using an endoscope that goes through the mouth and looks at a 45 degree angle, providing what I feel is good visualization. I have been curious as to what I could achieve with the robot technology, and I look forward to learning the results of their work. Currently, no sleep surgeons are being trained with the robot, which has been required by the FDA until more data are available to show a clear benefit.
The conference ended with my talk about new surgical treatments for obstructive sleep apnea. I discussed recent developments using magnets, tissue anchors, removal of tongue tissue, and hypoglossal nerve stimulation.
As always, I learned much from the conference and hope that everyone who attended did as well. This blog is not sufficient to explain the level of detail, but I hope the updates have provided a sense of some key findings presented here in Orlando.